Melatonin replacement and sleep program
|
|
- Deborah Williamson
- 5 years ago
- Views:
Transcription
1 Melatonin replacement and sleep program This questionnaire will take approximately 10 minutes to complete. The information you provide is very important and will assist our sleep specialists during the review of your sleep symptoms. This questionnaire has been compiled based on many years of accumulated experience in Sleep Medicine. The information will be treated with the utmost discretion and will not be used by any party other than Finlandia Pharmacy & Natural Health Centre. Please respond to all questions by completing the free text sections. If you have a bed partner, a parent or guardian, or otherwise someone who is willing to and is able to comment on your sleep patterns or behaviors during sleep please have them complete the BED PARTNER, PARENT OBSERVATION QUESTIONNAIRE at the end. Patient name: Scheduled Appointment Date: Phone Nr.: Sleep Specialist: Today s Date: Height (inches): DOB: Weight now (lbs): Age: Weight 1 year ago: Sex: Weight 5 years ago: I was referred by: Name of Doctor: Page 1 of 6
2 Sleep schedule How long have you had sleep problems? Weeks, months, years? Why do you think you can t sleep? What time do you go to bed on weekdays? What time do you go to bed on weekends? What time do you get out of bed on weekdays? What time do you get out of bed on weekends? Do you go to bed every day at the same time? (Including weekends) How much sleep do you get on an average night (hours)? Are you a morning type, evening type, neither? What would be your ideal bedtimes? Do you have periods of tiredness throughout the day? Do you nap? How often do you nap? (number of times per week) How long are the naps? (in minutes) Do you awaken refreshed from the nap? What are your usual work hours? Are you a shift worker? Do you travel often? If so are you exposed to jet leg? Do you have difficulty falling asleep? Do you have difficulty staying asleep? How fast do you fall asleep? Do you wake up too early and cannot get back to sleep? How many times do you wake up during the night? How long does it take you to fall asleep again? Do you sleep walk? Page 2 of 6
3 Snoring/Breathing history Do you snore? What is your preferred sleep position? Back (% of sleep time)? Left Side (% of sleep time)? Right Side (% of sleep time)? Stomach (% of sleep time)? Does your sleep position affect your snoring? Do you awaken with a snort, choking or gasping for air? Do you awaken with a headache? Has anyone noticed you stop breathing while asleep? Do you awaken often to urinate during the night? Do you awaken with acid or sour taste in your mouth? Do you have difficulty breathing while on your back? Do you sweat excessively during the night? Do you awaken with a dry mouth or sore throat? Abnormal movements/behaviors Do you have or have you ever experienced (Y/N): An urge to move your legs, usually accompanied by uncomfortable and unpleasant sensations in the legs? Discomfort in the legs that worsen during periods of rest or inactivity such as laying down or sitting? Discomfort in the legs that is relieved by movement: walking or stretching? Discomfort that worsens during the nighttime? Do you get cramps at night? Do you kick or jerk your arms or legs during sleep? Are your bed covers messy in the morning? Do you kick, punch, or poke your bed partner while asleep? Have you ever injured your bed partner or yourself? Page 3 of 6
4 Do you grind your teeth? Do you wear a bite splint (mouth guard)? Do you walk in your sleep? If yes, when was the last time? Do you talk in your sleep? Do you have nightmares or night terrors? Do you make rolling movements or bang and twist your head at night? Have you had sleep problems as a child? Sleeping room conditions Do you read in bed? Paper copies or electronically? Do you share the bed with anyone? Does your partner have a sleep disorder? Do you have pets sleep in the bedroom? Is your bedroom comfortable? Do you sleep in a completely dark bedroom? Blacked out windows? What types of lighting do you use? (LED, incandescent, fluorescent) What is your bedroom s temperature? Nutrition How much water do you drink per day? When do you drink water? Do you drink any sugary drinks? If yes, at what times and how close to going to bed? Do you consume any sugary foods? If yes, at what times and how close to going to bed? When do you eat your evening meals? What s a typical evening meal look like? Do you snack on anything else before you go to bed? If yes, how long before you go to bed? Page 4 of 6
5 Medications List current medications (name, dose, and number taken per day), including OTCs, vitamin/herbal supplements and homeopathics: Please also include any sleep remedies if applicable. Have you ever used other sleep medications before? If yes which and what results were obtained with each? Do you take any of the following? Antihistamines, alpha/beta blockers, or antidepressant? Stress levels and dreams Are you stressed at home or at work? Do you meditate or have quiet times alone? If so how much per day or week? Do you have fulfilling relationships (family, spouse, friends)? Do you have thoughts racing through your mind that make it difficult to sleep? Do you know about geopathic stress? Do you dream? If yes, are your dreams pleasant or disturbing? Do you remember your dreams? Do you remember at what time you dream? Electrical devises How often do you use electronics devices (i.e. cell phones, tablets, TVs)? (hours per day) Do you have any electronics devices in your bed room? Do you use any electronics devices (i.e. cell phones, tablets, TVs) within 2 hours of going to sleep? Are you exposed to any other EMFs (electromagnetic fields) while sleeping? (i.e. smart meters, WIFI, Bluetooth, cell phone signals, alarm clock, power lines nearby) Page 5 of 6
6 Other factors Do you use tobacco products? If yes, how often per day? Do you drink alcohol? If yes, how often per week? Do you drink caffeinated beverages? If yes, what type and how often per week? Do you use recreational drugs? (i.e. marihuana) If yes, what type and how often per week? Do you exercise? Do you get regular exercise? Is yes, what type of exercise? Level of intensity? And how often? Do you have any medication or environmental allergies? (pets, pollen, food, dust, etc.) Bed partner, parent observation questionnaire Do you live with the patient? Do you sleep in the same room as the patient? If no, is it because of his/her sleep behaviors (i.e. snores too loud acts out dreams, etc)? Check any of the following behaviors that you have observed the patient is doing while asleep and describe in detail. Include a description of the activity, the time during the night when it occurs, frequency during the night and whether it occurs every night. Waking up at night Waking up too early and cannot get back to sleep Irregular bed times Snoring General emotional instability Pauses in breathing Sleep-talking Sleep-walking Turbulent dreams Unhealthy lifestyle Please print the questionare with the folowing button and send it per fax to: Or save it after you re finish and send it per to: customerservice@finlandiahealth.com Page 6 of 6
PATIENT NAME: M.R. #: ACCT #: HOME TEL: WORK TEL: AGE: D.O.B.: OCCUPATION: HEIGHT: WEIGHT: NECK SIZE: GENDER EMERGENCY CONTACT: RELATIONSHIP: TEL:
SLEEP DISORDERS INSTITUTE HOSPITAL: DePaul Building Street Address City, State Zip Tel: (202) 555-1212 Fax: (202) 555-1212 SLEEP QUESTIONNAIRE PATIENT NAME: M.R. #: ACCT #: STREET ADDRESS: CITY: STATE:
More informationSLEEP HISTORY QUESTIONNAIRE
Date of birth: Today s date: Dear Patient: SLEEP HISTORY QUESTIONNAIRE Thank you for taking the time to fill out a sleep history questionnaire. This will help our healthcare team to provide the best possible
More informationPediatric Sleep History
Fax 423-431-2983 Pediatric Sleep History Patient/ Child s Name: Date of Birth: Parent Name: Last 4 of Social Security No: Gender: Male Female Height: Weight: Age: Race: Street Address: City: State: Zip:
More informationPatient History & Sleep Questionnaire
Patient History & Sleep Questionnaire Patient Full Name: Nick Name: Birth date: Age: Sex: Height: Current Weight: Weight Five Years Ago: Peak Lifetime Weight: Marital Status: Single Married Divorced Widowed
More informationSLEEP STUDY. Nighttime. 1. How many hours of sleep are you now getting in a typical night?
SLEEP STUDY Patient Name: Date of Birth: Date of Study: This questionnaire involves a broad range of sleep and sleep-related behaviors. Your answers enable us to develop a clearer picture of your sleep/wake
More informationSleep History Questionnaire
Sleep History Questionnaire Name: DOB: Phone: Date of Consultation: Consultation is requested by: Primary care provider: _ Preferred pharmacy: Chief complaint: Please tell us why you are here: How long
More informationAshok K. Modh, M.D., F.C.C.P. Naishadh K. Mandaliya, M.D., F.C.C.P. Jerges J. Cardona, M.D. Nirav B. Patel, M.D.
Ashok K. Modh, M.D., F.C.C.P. Naishadh K. Mandaliya, M.D., F.C.C.P. Jerges J. Cardona, M.D. Nirav B. Patel, M.D. Dear, Your physician has requested that you be scheduled for a sleep study. Your appointment
More informationAdolescent Sleep Disorder Questionnaire For Children Ages PATIENT NAME: (Please print clearly) Patient s Date of Birth: Age: Male Female
(PATIENT) Adolescent Sleep Disorder Questionnaire For Children Ages 12-17 Instructions: Please review this form for accuracy prior to submission. You may complete this information prior to arrival at the
More information130 Preston Executive Drive Cary, NC Ph(919) Fax(919) Page 1 of 6. Patient History
130 Preston Executive Drive Cary, NC 27513 Ph(919)462-8081 Fax(919)462-8082 www.parkwaysleep.com Page 1 of 6 Patient History *Please fill out in dark BLACK INK only. General Information Name Sex: Male
More informationSLEEP QUESTIONNAIRE. Name: Home Telephone. Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: Pharmacy & Phone #:
q JHMCE q JHS q SMEH SLEEP QUESTIONNAIRE 1. DEMOGRAPHIC DATA Name: Home Telephone Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: 2. PHYSICIAN INFORMATION Name of Primary
More informationSleep Questionnaire. Today s Date: DOB: Age: Marital Status: S M W D Gender: Occupation: Phone: Height: Current Weight: Weight 1 year ago:
Sleep Questionnaire Patient's Name: Referring Dr.: Today s Date: DOB: Age: Marital Status: S M W D Gender: Occupation: Phone: Height: Current Weight: Weight 1 year ago: Weight 5 years ago: 5 yrs ago: 10
More informationSleep History Questionnaire B/P / Pulse: Neck Circum Wgt: Pulse Ox
2700 Campus Drive, Ste 100 2412 E 117 th Street Plymouth, MN 55441 Burnsville, MN 55337 P 763.519.0634 F 763.519.0636 P 952.431.5011 F 952.431.5013 www.whitneysleepcenter.com Sleep History Questionnaire
More informationBaptist Health Floyd 1850 State Street New Albany, IN Sleep Disorders Center Lung & Sleep Specialists. Date of Birth: Age:
Page 1 of 7 GENERAL INFORMATION Name: Date of Birth: Age: Social Security #: Sex: Height: Weight: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Employer s Name: Marital Status: Married
More informationPatient Scheduled Letter Thunderbird Internal Medicine Sleep Center 5620 W. Thunderbird Rd., Suite C-1 Glendale, AZ (602)
Patient Scheduled Letter Thunderbird Internal Medicine Sleep Center 5620 W. Thunderbird Rd., Suite C-1 Glendale, AZ 85306 (602) 938 6960 Dear Patient, Your Doctor has requested you be scheduled for a sleep
More informationOccupation: Usual Work Hours/Days: Referring Physician: Family Physician (PCP): Marital status: Single Married Divorced Widowed
Name Social Security No. Last First MI Address Phone No. ( ) City State Zip Secondary No. ( ) Date of Birth Sex (M/F) Race Email County Primary Care Marital Status Single Divorced Married Widowed Employer
More information*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
More informationTHE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk PATIENT QUESTIONNAIRE
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk 55 Frid Street, Unit 7, Hamilton, Ontario L8P 4M3 Phone:905-529-2259 Fax: 905-529-2262 282 Linwell Road, Suite 118, St. Catharines, Ontario
More informationSLEEP DISORDERS CENTER QUESTIONNAIRE
Carteret Health Care Patient's name DOB Gender: M F Date of Visit _ Referring physicians: Primary care providers: Please complete the following questionnaire by filling in the blanks and placing a check
More informationPULMONARY & CRITICAL CARE CONSULTANTS OF AUSTIN 1305 West 34 th Street, Suite 400, Austin, TX Phone: Fax:
Name: Sex: Age: Date: Date of Birth Height Weight Neck size Referring Physician: Primary Care MD: Main Sleep Complaint(s) trouble falling asleep trouble remaining asleep excessive sleepiness during the
More informationSleep Disorders Diagnostic Center 9733 Healthway Drive, Berlin, MD , ext. 5118
Sleep Questionnaire *Please complete the following as accurate as possible. Please bring your completed questionnaire, insurance card, photo ID, Pre-Authorization and/or Insurance referral form, and all
More informationSleep Symptoms & History
Sleep Symptoms & History In your own words, please tell us what brings you to the sleep clinic today? How long have you been experiencing your sleep problems? yrs. mos. To give us a precise understanding
More informationAssociated Neurological Specialties and Sleep Disorder Center
Sleep Center Questionnaire Name: Sex: Age: Date: Date of Birth: Height: Weight: Neck Size: Primary Care Physician: Referring Physician: Main Sleep Issues/Complaints Trouble falling asleep Trouble staying
More informationTHE PERMANENTE MEDICAL GROUP
Patient label here THE PERMANENTE MEDICAL GROUP Division of Sleep Medicine COMPLETED BY: PARENT/GUARDIAN CHILD/ADOLESCENT Age: Height: Weight: PEDIATRIC SLEEP QUESTIONNAIRE Thank you completing this questionnaire.
More informationSleep Disorders Center of Santa Maria
SLEEP QUESTIONNAIRE Patient Name: Sex: Date of Birth: Occupation: Usual Work Hours/Days: Referring Physician: Family Physician: Marital status: Single Married Divorced Widowed Please complete the following
More informationPEDIATRIC SLEEP QUESTIONNAIRE. Child s Name:,, Last First MI. Name of Person Answering Questions: Relation to child:
PEDIATRIC SLEEP QUESTIONNAIRE Child s Name:,, Last First MI Name of Person Answering Questions: Relation to child: Your phone number, Days: and Evenings: Area Code Number Area Code Number Relative s name
More informationMEDICAL HISTORY QUESTIONNAIRE
MEDICAL HISTORY QUESTIONNAIRE NAME: SEX: DATE: DOB: AGE: Primary Doctor / Care Manager: Additional doctors to receive sleep study results: Chief sleep related complaint: What made you decide to have this
More informationPolysomnography Patient Questionnaire
Polysomnography Patient Questionnaire Date Medical Record # Demographics: Patient Name Date of Birth Address_ Home Phone Work Phone Cell Phone Height Weight Please complete each section of this questionnaire,
More informationSleep Questionnaire. 2. How long has this problem bothered you? My Main Sleep Complaints: - Trouble sleeping at night For how many months/ years?
Onslow Medical Specialties Clinic Lung Diseases & Sleep Disorders Clinic Pulmonary Function Test/ CardioPulmonary Exercise Test/ Thoracic Ultrasound Methacholine Challenge Test/ Video-Flexible Laryngoscopy/
More informationPatient Information. Name: Date of Birth: Address: Number & Street City State Zip Code. Home Number: ( ) Cell Number: ( )
Patient Information Name: Date of Birth: Age: Address: Number & Street City State Zip Code Home Number: ( ) Cell Number: ( ) Social Security Number: Marital Status: Religion: Race: Height: Weight: Sex:
More informationSLEEP QUESTIONNAIRE. Name: Sex: Age: Date: DOB: / / SSN: - - Address: Referring Physician: Family Physician: Height: Weight: Neck Size: Phone:
SLEEP QUESTIONNAIRE Name: Sex: Age: Date: DOB: / / SSN: - - Address: Referring Physician: Family Physician: Height: Weight: Neck Size: Phone: Please fill in the blanks, and check appropriate areas on the
More informationGeneral Information. Name Age Date of Birth. Address Apt. # City State Zip. Home Phone Work Phone. Social Security Number Marital Status
Accredited Member Center of The American Academy of Sleep Medicine 400 Riverside Drive, Suite 1500, Bourbonnais, IL 60914 Phone (815) 933-2874 Fax (815) 939-9413 www.riversidemc.net/sleep General Information
More informationThe Medical Center Sleep Center
The Medical Center Sleep Center Date: / / Name: Age: (First) (M.I.) (Last) Address: (Street / P.O. Box) (City) (State) (Zip) (County) Phone: Home ( ) Work ( ) Date of Birth: / / Education: Marital Status:
More informationGeneral Questionnaire
General Questionnaire Name: Date: Address:_ Home Phone: Alternate number: Occupation: Age: Height: Weight: Weight 6 months ago: At age 20: At your heaviest: Referring Physician: Family Physician: 1. In
More informationPATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS NPSG CPAP CPAP Retitration Split Night PATIENT INFORMATION: Name: Last First Middle Initial Address: City: State: Zip: Social Security #: DOB: Gender: Age: Phone Number: Cell: Work:
More informationSLEEP QUESTIONNAIRE. Please briefly describe your sleep or sleep problem:
SLEEP QUESTIONNAIRE Your answers to the following questions will help us to obtain a better understanding of your sleep problems. Please answer every question to the best of your ability. It is helpful
More informationSection of Pediatric Sleep Medicine
Section of Pediatric Sleep Medicine David Gozal, MD Hari Bandla, MD Date: Dear Parent or Caregiver; Thank you for your interest in the Sleep Disorders Program. The sleep clinic s standard assessment procedure
More informationPATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:
More informationNot Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy
Health Benefits Employee Services HBE Preventive Health - Sleep Assessment Form Please bring your completed assessment form to your appointment. To schedule an appointment please call 505 844-HBES (4237).
More informationSleep Questionnaire Name: Sex: Age: Da te: Da te of birth: Height: Weight: Neck siz e: Ref erring Physician: Primary Car e MD:
www.myvcmf.com 1133 E. Stanley Blvd., Suite 101 Livermore, CA 94550 925 454-4280 5725 W. Las Positas Blvd., Suite 110 Pleasanton, CA 94588 925-416-6767 Sleep Questionnaire Name: Sex: Age: Da te: Da te
More information604 NORTH ACADIA ROAD, Suite 210 THIBODAUX, LA SLEEP HISTORY QUESTIONNAIRE
604 NORTH ACADIA ROAD, Suite 210 THIBODAUX, LA 70301 985-493-4759 SLEEP HISTORY QUESTIONNAIRE DATE: / / NAME: AGE (First) (Middle) (Last) ADDRESS: (Street) (City) (State) (Zip) PHONE: Home( ) Work:( )
More informationHumble Dreams Sleep Center. Humble, TX 77339
Humble Dreams Sleep Center 8901 FM 1960 Bypass West, Ste. 306 Humble, TX 77339 Dear Humble Dreams Sleep Study Patient, Thank you for allowing Humble Dreams Sleep Center to provide your sleep study as requested
More informationEmergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax:
SUNSET SLEEP LABS PATIENT INFORMATION FORM Patient Information Name: Sex: M F Date of Birth: Address/Street: City: Zip: Phone: Alt Phone: Parent/Guardian: Phone: Social Security Number: Drivers License:
More informationPATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
More informationDenver, CO Welcome Packet
Fax: (303) 957-5414 or 720-542-8699 For any after-hours questions, please call (303) 956-5145 Dear Mountain Sleep Patient, You have been scheduled for a sleep study at 1210 S Parker Road, Suite 101, Denver,
More informationFacial Problem(s) Questionnaire
Facial Problem(s) Questionnaire Full Legal Name: _ Birth Date: Referred by: Referring Dr s Phone#: Referring Dr s Email address: _ Christopher M. Anderson, DMD 1225 Johnson Ferry Road Suite 660 Marietta,
More informationPediatric Sleep Questionnaire
Pediatric Sleep Questionnaire Date Child's Name: Age Gender DOB Referring Physician: Primary Care Physician: Please answer fill out the following questionnaire regarding your child's sleep: What are your
More informationVCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
More informationSleep Medicine Questionnaire
Please bring this completed questionnaire with you to your sleep medicine appointment. Our sleep medicine staff strives to understand your sleep symptoms, which may be complex in nature. Thank you for
More informationSLEEP DISORDERS INVENTORY
1090 Amsterdam, 17th Floor New York, New York 10025 212-994-5100 Toll Free: 888-SLEEP-NY Fax: 212-994-5101 SLEEP DISORDERS INVENTORY Gary K. Zammit, Ph.D., Stephen Lund, M.D., Joseph Ghassibi, M.D., Kathleen
More informationLittleton, CO Welcome Packet 8151 Southpark Lane, Suite 200 Littleton, CO 80120
Littleton, CO Welcome Packet For any after-hours questions, please call (303) 956-5145 Dear Mountain Sleep Patient, You have been scheduled for a sleep study at 8151 Southpark Lane, Suite 200, Littleton,
More informationPediatric Patient ST CHARLES HOSPITAL SLEEP DISORDERS CENTER SLEEP QUESTIONNAIRE FOR PEDIATRIC PATIENTS PATIENT INFORMATION. PATIENT NAME Male Female
ST CHARLES HOSPITAL SLEEP DISORDERS CENTER SLEEP QUESTIONNAIRE FOR PEDIATRIC PATIENTS PATIENT INFORMATION PATIENT NAME Male Female ADDRESS DATE OF BIRTH AGE SOCIAL SECURITY # HOME TELEPHONE # ( ) CELL
More informationSleep Medicine Associates
Date: Patient Name: DOB: Patient Height: _ Weight: _ lbs Referring Physician: Neck Size: Main Sleep Problems: 1. My main sleep complaint is: Trouble Sleeping at night Sleepy during the day Unusual behavior
More informationPlease complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. For how many months/years?
St. Louis Heart and Vascular - McKelvey Office May 28, 2018 (Page 1) Please complete the following questionnaire by filling in the blanks and placing a check in appropriate areas. Today s Date: My Main
More informationLIBERTY SLEEP ASSOCIATES, LLC SLEEP DISORDERS CENTER
SLEEP QUESTIONNAIRE Patient Name: Sex: Age: Date: Occupation: Usual Work Hours/Days: Family Physician (PCP): Ht Wt Neck Size: What was your weight one year ago? Five years ago? Marital status: (circle
More informationHEALTHY LIFESTYLE, HEALTHY SLEEP. There are many different sleep disorders, and almost all of them can be improved with lifestyle changes.
HEALTHY LIFESTYLE, HEALTHY SLEEP There are many different sleep disorders, and almost all of them can be improved with lifestyle changes. HEALTHY LIFESTYLE, HEALTHY SLEEP There are many different sleep
More informationWHY CAN T I SLEEP? Deepti Chandran, MD
WHY CAN T I SLEEP? Deepti Chandran, MD Sleep and Aging How does sleep change as we age? Do we need less sleep as we get older? Can a person expect to experience more sleep problems or have a sleep disorder
More informationWELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
More informationIowa Sleep Disturbances Inventory (ISDI)
Department of Psychological & Brain Sciences Publications 1-1-2010 Iowa Sleep Disturbances Inventory (ISDI) Erin Koffel University of Iowa Copyright 2010 Erin Koffel Comments For more information on the
More informationSLEEP & MEDICAL HISTORY QUESTIONNAIRE
SLEEP & MEDICAL HISTORY QUESTIONNAIRE Patient Name Sex Age Date Please complete the following questionnaire by placing a check in the appropriate areas and filling in the blanks. My Main Sleep Complaint(s)
More informationI would like for my patient to be seen in Sleep Medicine consultation and managed by the sleep physician. Yes No
701 E. COUNTY LINE ROAD, SUITE 207. GREENWOOD, IN. 46143 OFFICE317-887-6400 FAX 317-887-6500 indianasleepcenter.com REFERRAL FOR SLEEP EVALUATION Patient Name:_ Phone: I would like for my patient to be
More informationSleep Study Information
Sleep Study Information Metroplex Hospital Sleep Center 2111 S. Clear Creek Rd. Killeen, TX 76549 (254) 519-8452 Report to sleep lab at your scheduled appointment time, do not arrive before this time.
More informationRobert E. McMichael, M.D. Medical Director Patient Instructions for a Diagnostic Sleep Study
NORTH TEXAS SLEEP DISORDERS CENTER Neurology Associates of Arlington, P.A 811 West Interstate 20, Suite G12 Arlington, Texas 76017 (817) 419-6375 Fax (817) 419-6371 Robert E. McMichael, M.D. Medical Director
More informationIntake Questionnaire
Intake Questionnaire In order to make the best use of your appointment time, please complete this form prior to your initial appointment. What is your name? (Who filled in this form?) (Y= yes N=no DK=
More informationInterview Team: INTERVIEW QUESTIONNAIRE: Teenage Sleep Clinic
Interview Team: Date: INTERVIEW QUESTIONNAIRE: Teenage Sleep Clinic The aim of this questionnaire is to learn more about you, your habits, and your sleep. This will help us to understand about the problems
More informationA good night s sleep
A good night s sleep Delivering the best in care UHB is a no smoking Trust To see all of our current patient information leaflets please visit www.uhb.nhs.uk/patient-information-leaflets.htm A good night
More informationMaintenance for Wakefulness Testing (MWT)
SLEEP DISORDERS CENTER St. Joseph Mercy Ann Arbor 5305 Elliott Drive, Ypsilanti, MI 48197 734-712-2276 / Fax 734-712-2967 Maintenance for Wakefulness Testing (MWT) Dear, Your Maintenance for Wakefulness
More informationNash Sleep Disorders Center 250 Medical Arts Mall Suite C Rocky Mount NC Phone: Fax:
Appointment Date: Arrival Time: *Please give at least 24 hour notice if you are unable to keep your appointment or need to reschedule. 1. Patients will need to bring pictured identification, insurance
More informationMaintenance for Wakefulness Testing (MWT)
Maintenance for Wakefulness Testing (MWT) Dear, Your Maintenance for Wakefulness Testing (MWT) will begin on the morning of at 7 a.m. and will end at 5 p.m. ARRIVAL TIME: If you are not able to arrive
More informationYOUR NAME AGE DATE. Comments. Describe your sleep problem and how long you ve had it
YOUR NAME AGE DATE Describe your sleep problem and how long you ve had it Have you ever been at a sleep center before? YES NO When? Where? Ever been on CPAP? YES NO WORK SCHEDULE When does your usual work
More informationTallahassee Memorial Sleep Center Patient Questionnaire
Tallahassee Memorial Sleep Center Patient Questionnaire Name _ Age Date Date of Birth Sex Height ft in Weight lbs Neck size inches (If known) Body Mass Index (BMI) (If known) Phone(s) (home) (work) (cell)
More informationOriginal Sleep Hygiene Rules*
Original Sleep Hygiene Rules* 1. Sleep as much as needed to feel refreshed and healthy during the following day, but not more. Curtailing time in bed a bit seems to solidify sleep; excessively long times
More informationSLEEP STUDY CANCELLATION/ NO SHOW POLICY
Olusegun Oseni, MD F.C.C.P. 945 Hilltop Dr, Ste 101 Weatherford, Texas 76068 Phone: 817-594-9993 Fax: 817-594-9915 SLEEP STUDY CANCELLATION/ NO SHOW POLICY Dear Patient: We understand that emergencies
More informationHuron Medical Sleep Center Saad S. Ahmad, MD
Authorization and Consent for Sleep Testing I authorize the release of any medical information necessary to the durable medical equipment company for therapy, if applicable. I authorize the use of audio
More informationNew Patient Sleep Intake
New Patient Sleep Intake Name: Date of Birth: Primary Care Physician: Date of Visit: Referring Physician and/or Other Physicians: Retail Pharmacy: Mail Order Pharmacy: Address: Mail Order Phone #: Phone
More informationSleep History Questionnaire. Sleep Disorders Center Duke University Medical Center. General Information. Age: Sex: F M (select one)
Sleep History Questionnaire Sleep Disorders Center Duke University Medical Center Part I: General Information Name: Address: Date: Phone: Age: Sex: F M (select one) Education (years of school): Occupation:
More informationSleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
Patient Label For office use only Appt date: Clinician: Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 Leading
More informationDate of Study: Arrive at: P.M.
Date of Study: Arrive at: P.M. Depart at 5: AM (Note: Sleep technicians leave the premises at 6 AM) Please notify the Palos Pulmonary staff in advance if you require any special assistance / accommodations
More informationSLEEP EVALUATION QUESTIONNAIRE
Specialty Care Center SLEEP PROGRAM Patient Questionnaire ------------------------------------------------------------------------------------------------------------------------------------------ SLEEP
More informationPlease complete this questionnaire before your appointment.
Date completed: Please complete this questionnaire before your appointment. Name: Occupation: Age: Birth date: Gender: M / F Height: Weight: Weight in High School: Neck Size: in. Ethnicity: Hispanic or
More informationInsomnia. F r e q u e n t l y A s k e d Q u e s t i o n s
Insomnia Q: What is insomnia? A: Insomnia is a common sleep disorder. If you have insomnia, you may: Lie awake for a long time and have trouble falling asleep Wake up a lot and have trouble returning to
More informationHeight: Weight: Neck Size: Does your work involve shift work? Yes No. Where did you hear about us: Physician Media Friend Other
Personal Information Name: Date of birth: Sex: Male Female Marital Status: Nationality: MRN(for KAUH Patients): Height: Weight: Neck Size: Address: Occupation: Length of work day: Does your work involve
More informationSleep Study Appointment Date: Time: 8:00 PM
100 West Fourth Street, Suite 350 Cookeville, TN 38501 (931) 783-2753 Fax: (931) 783-2036 Patient Name: Sleep Study Appointment Date: Time: 8:00 PM We are located at the corner of 4 th Street and Cedar
More informationNarendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine
Narendra Kumar, M.D. PC Board Certified ENT Board Certified Sleep Medicine PATIENT DEMOGRAPHICS Who is the Physician that referred you to us? Who is the primary care Physician? Date: Do you want this report
More informationKelowna Sleep Clinic Dr. Ronald Cridland Inc Sleep Questionnaire
Dr. Ronald Cridland Inc Sleep Questionnaire Name: Date: d/m/yr Date of Birth: d/m/yr Age: Marital Status: Sex: M F Address: City: Province: Postal Code: Health Care #: Home Phone #: Work Phone #: _ Cell
More information993 C Johnson Ferry Road, Suite 300 Robert J Albin, MD
993 C Johnson Ferry Road, Suite 300 Robert J Albin, MD Atlanta, Georgia 30342 David E Westerman, MD 404-303-1700/ Fax: 404-252-9527 Alex Hebert, NP-C To our New Sleep Patient: On behalf of North Atlanta
More informationHealthy Sleep Tips Along the Way!
Women and Sleep What You Will Learn The Benefits and Importance of Sleep States and Stages of the Sleep Cycle Unique Physiology of Women s Sleep Common Disorders in Women that Affect Sleep Women s Role
More informationALLIANCE COMMUNITY HOSPITAL SLEEP DISORDERS CENTER PATIENT QUESTIONNAIRE/HISTORY PLEASE COMPLETE AND BRING WITH YOU ON THE NIGHT OF YOUR TEST.
ALLIANCE COMMUNITY HOSPITAL SLEEP DISORDERS CENTER PATIENT QUESTIONNAIRE/HISTORY PLEASE COMPLETE AND BRING WITH YOU ON THE NIGHT OF YOUR TEST. NAME DATE: HEIGHT: WEIGHT: DOB: SEX: HOME PHONE #: REFERRING
More informationParticipant ID: If you had no responsibilities, what time would your body tell you to go to sleep and wake up?
What does your sleep look like on a typical week? Total Sleep Time: Bedtime:, Sleep onset latency:, Number of Awakenings:, Wake time after sleep onset:, Rise time:, Out of bed:, Naps:? Notes: Is your sleep
More informationSleep History Questionnaire
Location South Loop Katy Steeplechase Fort Bend NAME ADDRESS PHONE SEX DOB AGE HEIGHT WEIGHT NECK COLLAR SIZE (inches) Do you have difficulty falling asleep? Is your sleep restless or disturbed? Do you
More information1960 FP CENTER FOR SLEEP DISORDERS
1960 FP CENTER FOR SLEEP DISORDERS Sleep Questionnaire Name: Date: Date of Birth: / / Age: Gender: Height: Weight: lbs. Referring Physician: Occupation: Please give a brief description of your sleep problem
More informationPATIENT SLEEP QUESTIONNAIRE
PATIENT SLEEP QUESTIONNAIRE Name: Date of Birth: Today s Date Primary Care Physician Telephone # Physician ordering test (Other than PCP): Physician s Tel. #: _ Age: Years Height: Feet Inches Weight: Lb
More informationA NIGHT IN THE SLEEP FACILITY
A NIGHT IN THE SLEEP FACILITY The architecture of sleep that is, the distribution of sleep stages is revealed through sleep studies. Excessive sleepiness, insomnia, depression and disturbing physical events
More informationSleep Center of Willmar LLC
Sleep Center of Willmar LLC 1801 19 th Avenue South West Willmar, MN. 56201 320-441-2104 (telephone) 320-441-2052 (facsimile) Welcome Our staff understands that quality care and patient comfort go hand
More informationHome Sleep Testing Questionnaire
Home Sleep Testing Questionnaire Patient Name: DOB: / / Gender: Male Female Study Date: / / Marital Status: Married Cohabitate Single Divorced Widow/Widower Email: Phone: Height: Weight: Neck Size: What
More informationPATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely
PATIENT QUESTIONNAIRE Salem Sleep Medicine Please fill out completely Date: email address: First name: Middle: Last: Nickname: Ethnicity/Race (please circle): Black or African American Caucasian Hispanic
More informationPEDIATRIC SLEEP EVALUATION
PEDIATRIC SLEEP EVALUATION Directions: Please answer each of the following questions by writing in or choosing the best answer. This will help us know more about your family and your child. CHILD S INFORMATION
More informationPEDIATRIC HISTORY FORM
Lehigh Valley Health Network Pediatric Sleep Center PEDIATRIC HISTORY FORM Please answer the following questions frankly and accurately by filling in the blank or checking/circling the appropriate answer.
More informationSLEEP SCREENING QUESTIONNAIRE
Patient Information 433 W. University Dr. Rochester, MI 48307 www.rochesteradvanceddentistry.com +1 248 656-2020 SLEEP SCREENING QUESTIONNAIRE Name: DOB: Age: Address: Employer: SS# Home Phone: Work Phone:
More informationALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION
ALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION LEGAL Name Date of Birth (must match insurance card) Address City State Zip Mailing Address City State Zip (If different) Phone: Cell Home Appt. reminders
More informationDr. Michael Baten is The Santa Fe SleepDoctor NEUROLOGY / ADULT AND PEDIATRIC SLEEP MEDICINE
Dear Patient, Please complete the enclosed paperwork in which you provide information regarding your sleep problem, and bring it with you to your appointment with Dr. Baten scheduled for: Date: _ Time:
More information